STONEBRIDGE CASUALTY INSURANCE COMPANY Home Office: Columbus, Ohio ADMINISTRATIVE OFFICE: 100 LIGHT STREET BALTIMORE, MARYLAND 21202

Transcription

1 1STA0912W (1STA Washington Policy) Home Office: Columbus, Ohio ADMINISTRATIVE OFFICE: 100 LIGHT STREET BALTIMORE, MARYLAND This Policy is issued to you. The Policy is issued in consideration of payment of premiums as provided by its terms. We agree to pay benefits in accordance with all the provisions of this Policy. Premiums are payable to us or our agent in amounts as set forth by us. The provisions found on the following attached pages form a part of this Policy as if recited over the signatures shown below. TEN DAY RIGHT TO EXAMINE POLICY If you are not satisfied for any reason, you may return this Policy within 10 days after receipt. Your premium will be refunded. When so returned, the Policy is void from the beginning. Return the Policy to us at our Administrative Office or to our authorized agent. This Policy is executed on the Effective Date, at Columbus, Ohio. INDIVIDUAL TRAVEL INSURANCE POLICY ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS MEDICAL EXPENSE BENEFITS EMERGENCY ASSISTANCE BENEFITS NONPARTICIPATING

2 TABLE OF CONTENTS BENEFIT AND PREMIUM RATE SCHEDULE... 2 WHEN COVERAGE BEGINS... 3 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT... 3 MEDICAL EXPENSE BENEFITS... 3 EMERGENCY ASSISTANCE BENEFITS... 4 DEFINITIONS... 4 EXCLUSIONS... 5 WHEN COVERAGE ENDS... 6 GENERAL PROVISIONS... 6 CLAIMS PROVISIONS... 7 AMENDMENT... 8 RIDERS OUTLINE OF COVERAGE SCHEDULE Insured: The words "you," "your," and "yours" means the Insured. Policy Number: Refer to your Policy Confirmation Letter Effective Date of Coverage: Refer to your Policy Confirmation Letter Premium Amount: Refer to your Policy Confirmation Letter Benefit Schedule for Plan Code 1STA: Maximum Benefit Amount Accidental Death and Dismemberment... $20,000 Policy maximum Air Flight Coverage... $50,000 Policy maximum Medical Expense/Emergency Assistance Split Limit Coverage Emergency Medical Evacuation... $250,000 Policy maximum Accident/Sickness Medical Expense... $100,000 Policy maximum Repatriation... $250,000 per Policy included in Medical Evacuation Trips: Refer to your Policy Confirmation Letter Trip Duration/Cost/Destination Refer to your Policy Confirmation Letter Premium Rate Per Person Refer to your Policy Confirmation Letter WHO IS ELIGIBLE FOR COVERAGE A person who has arranged to take a Trip, pays the required premium, and is a resident of the United States of America. TAHC5100IPS Page 2

3 TAHC5100IPS WHEN COVERAGE BEGINS All coverages will take effect on the later of 1) the date the premium has been received by us; 2) the date and time you start your Trip; or 3) 12:01 A.M. Standard Time on the Scheduled Departure Date of your Trip. ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS We will pay this benefit up to the amount on the Schedule if you are injured in an Accident which occurs while you are on a Trip and covered under the policy, and you suffer one of the losses listed below within 180 days of the Accident. The Principal Sum is the benefit shown on the Schedule. Loss: Page 3 Percentage of Principal Sum Payable: Life 100% Both Hands; Both Feet or Sight of Both Eyes 100% One Hand and One Foot 100% One Hand and Sight of One Eye 100% One Foot and Sight of One Eye 100% One Hand; One Foot or Sight of One Eye 50% If you suffer more than one loss from one Accident, we will pay only for the loss with the larger benefit. Loss of a hand or foot means complete severance at or above the wrist or ankle joint. Loss of sight of an eye means complete and irrecoverable loss of sight. Air Flight Benefits The benefits provided by the policy for Air Flight applies only if you sustain a covered loss in an Accident which occurs while a passenger in or on, boarding or alighting from an aircraft of a regularly scheduled airline or an air charter company that is licensed to carry passengers for hire. Exposure and Disappearance If by reason of an Accident covered by the policy, you are unavoidably exposed to the elements and as a result of such exposure suffer a loss for which benefits are otherwise payable, such loss shall be covered hereunder. If you are involved in an Accident which results in the sinking or wrecking of a conveyance in you were riding and your body is not located within one year of such Accident, it will be presumed that you suffered loss of life resulting from Injury caused by the Accident. MEDICAL OR DENTAL EXPENSE BENEFITS We will pay this benefit, up to the amount on the Schedule for the following Covered Expenses incurred by you, subject to the following: 1) Covered Expenses will only be payable at the Usual and Customary level of payment; 2) benefits will be payable only for Covered Expenses resulting from a Sickness that first manifests itself or an Injury that occurs while on a Trip.; 3) benefits payable as a result of incurred Covered Expenses will only be paid after benefits have been paid under any Other Valid and Collectible Group Insurance in effect for you. We will pay that portion of Covered Expenses which exceed the amount of benefits payable for such expenses under your Other Valid and Collectible Group Insurance. Please refer to the Definitions for an explanation of Pre-Existing Conditions which are excluded under the Medical or Dental Expense Benefits. Covered Medical or Dental Expenses: (1) expenses for the following Physician-ordered medical services: services of legally qualified Physicians and graduate nurses, charges for Hospital confinement and services, local ambulance services, prescription drugs and medicines, and therapeutic services, incurred by you within one year from the date of your Sickness or Injury during a Trip and; (2) expenses for emergency dental treatment incurred by you during a Trip. Your duties in the event of a Medical or Dental Expense: (1) You must provide us with all bills and reports for medical and/or dental expenses claimed. (2) You must provide any requested information, including but not limited to, an explanation of benefits from any other applicable insurance. (3) You must sign a patient authorization to release any information required by us to investigate your claim.

4 EMERGENCY ASSISTANCE BENEFITS We will pay this benefit, up to the amount on the Schedule for the following Covered Expenses incurred by you, subject to the following: 1) Covered Expenses will only be payable at the Usual and Customary level of payment; 2) benefits will be payable only for Covered Expenses resulting from a Sickness that first manifests itself or an Injury that occurs while on a Trip.; 3) benefits payable as a result of incurred Covered Expenses will only be paid after benefits have been paid under any Other Valid and Collectible Group Insurance in effect for you. We will pay that portion of Covered Expenses which exceed the amount of benefits payable for such expenses under your Other Valid and Collectible Group Insurance. Please refer to the Definitions for an explanation of Pre-Existing Conditions which are excluded under the Emergency Assistance Benefits. Covered Expenses (Emergency Assistance): (1) expenses incurred by you for Physician-ordered emergency medical evacuation, including medically appropriate transportation and necessary medical care en route, to the nearest suitable Hospital, when you are critically ill or injured and no suitable local care is available, subject to the Program Medical Advisors prior approval; (2) expenses incurred for non-emergency medical evacuation, including medically appropriate transportation and medical care en route, to a Hospital or to your place of residence in the United States of America when deemed medically necessary by the attending Physician, subject to the Program Medical Advisors prior approval; (3) expenses for transportation not to exceed the cost of one round-trip economy class air fare to the place of hospitalization for one person chosen by you, provided that you are traveling alone and are hospitalized for more than 7 days; (4) expenses for transportation not to exceed the cost of one-way economy class air fare to your place of residence in the United States of America, including escort expenses, if you are 18 years of age or younger and left unattended due to the death or hospitalization of an accompanying adult(s), subject to the Program Medical Advisors prior approval; (5) expenses for one-way economy class air fare (or first class, if your original tickets were first class) to your place of residence in the United States of America, from a medical facility to which you were previously evacuated, less any refunds paid or payable from your unused transportation tickets, if these expenses are not covered elsewhere in this policy; (6) repatriation expenses for preparation and air transportation of your remains to your place of residence in the United States of America, or up to an equivalent amount for a local burial in the country where death occurred, if you die while outside the United States of America. DEFINITIONS ACCIDENT means a sudden, unexpected, unintended and external event, which causes Injury. DOMESTIC PARTNER means a person who is at least eighteen years of age and you can show: 1) evidence of financial interdependence, such as joint bank accounts or credit cards, jointly owned property, and mutual life insurance or pension beneficiary designations; 2) evidence of cohabitation for at least the previous 6 months; and 3) an affidavit of domestic partnership if recognized by the jurisdiction within which they reside. ELECTIVE TREATMENT AND PROCEDURES means any medical treatment or surgical procedure that is not medically necessary including any service, treatment, or supplies that are deemed by the federal, or a state or local government authority, or by us to be research or experimental or that is not recognized as a generally accepted medical practice. HOME means your primary or secondary residence. HOSPITAL means an institution, which meets all of the following requirements: (1) it must be operated according to law; (2) it must give 24 hour medical care, diagnosis and treatment to the sick or injured on an inpatient basis; (3) it must provide diagnostic and surgical facilities supervised by Physicians; (4) registered nurses must be on 24 hour call or duty; and TAHC5100IPS Page 4

5 (5) the care must be given either on the hospital's premises or in facilities available to the hospital on a pre-arranged basis. A Hospital is not: a rest, convalescent, extended care, rehabilitation or other nursing facility; a facility which primarily treats mental illness, alcoholism, or drug addiction (or any ward, wing or other section of the hospital used for such purposes); or a facility which provides hospice care (or wing, ward or other section of a hospital used for such purposes). IMMEDIATE FAMILY MEMBER includes your or the Traveling Companion's dependent, spouse, child, spouse's child, son/daughter-in-law, parent(s), sibling(s), grandparent(s), grandchild, step-brother/sister, step-parent(s), parent(s)-in-law, brother/sister-in-law, uncles, aunts, niece, nephew, guardian, Domestic Partner, foster-child, or ward. INJURY means bodily harm caused by an Accident which: 1) occurs while the Insured s coverage is in effect under the plan; and 2) requires examination and treatment by a Physician. The Injury must be the direct cause of loss and must be independent of all other causes and must not be caused by, or result from, Sickness. OTHER VALID AND COLLECTIBLE GROUP INSURANCE means any group policy or contract which provides for payment of medical expenses incurred because of Physician, nurse, dental or Hospital care or treatment; or the performance of surgery or administration of anesthesia. The policy or contract providing such benefits includes group or blanket insurance policies; service plan contracts; employee benefit plans; or any plan arranged through an employer, labor union, employee benefit association or trustee; or any group plan created or administered by the federal or a state or local government or its agencies. In the event any other group plan provides for benefits in the form of services in lieu of monetary payment, the usual and customary value of each service rendered will be considered a Covered Expense. PHYSICIAN means a person licensed as a medical doctor by the jurisdiction in which he/she is resident to practice the healing arts. He/she must be practicing within the scope of his/her license for the service or treatment given and may not be you, a Traveling Companion, or an Immediate Family Member of yours. PRE-EXISTING CONDITION means an illness, disease, or other condition during the 60 day period immediately prior to your effective date for which you or your Traveling Companion or Immediate Family Member is scheduled or booked to travel with you: (1) received or received a recommendation for a diagnostic test, examination, or medical treatment; or (2) took or received a prescription for drugs or medicine. Item (2) of this definition does not apply to a condition which is treated or controlled solely through the taking of prescription drugs or medicine and remains treated or controlled without any adjustment or change in the required prescription throughout the 60 day period before coverage is effective under this policy. SCHEDULED DEPARTURE DATE means the date on which you are originally scheduled to leave on your Trip. SCHEDULED RETURN DATE means the date on which you are originally scheduled to return to the point where the Trip started or to a different final destination. SICKNESS means an illness or disease of the body which: 1) requires examination and treatment by a Physician, and 2) commences while the policy is in effect. TRAVELING COMPANION means a person whose name(s) appear(s) with you on the same Trip arrangement. TRIP means a scheduled trip for which coverage has been elected and the premium paid, and all travel arrangements are arranged prior to the Scheduled Departure Date of the Trip. USUAL AND CUSTOMARY CHARGE means those charges for necessary treatment and services that are reasonable for the treatment of cases of comparable severity and nature. This will be derived from the mean charge based on the experience in a related area of the service delivered and the MDR (Medical Data Research) schedule of fees valued at the 90th percentile. EXCLUSIONS The following exclusion applies to the Accidental Death and Dismemberment coverage: TAHC5100IPS Page 5

6 (1) We will not pay for loss caused by or resulting from Sickness of any kind. The following exclusion applies to the Emergency Assistance coverage: (2) We will not pay for loss or expense caused by or incurred resulting from a Pre-Existing Condition, as defined in this policy, including death that results therefrom. This Exclusion does not apply to benefits under Covered Emergency Assistance Expenses item # 1 and item # 2 (emergency medical evacuation) or item #6 (repatriation of remains). The following exclusion applies to the Medical or Dental Expense coverage: (3) We will not pay for loss or expense caused by or incurred resulting from a Pre-Existing Condition, as defined in this Policy, including death that results therefrom. The following exclusion applies to all coverages: (4) We will not pay for any loss under this policy, caused by, or resulting from: a) suicide, attempted suicide, or intentionally self-inflicted injury of you, a Traveling Companion, or Immediate Family Member booked to travel with you, while sane or insane; b) mental, nervous, or psychological disorders; c) being under the influence of drugs or intoxicants, unless prescribed by a Physician; d) normal pregnancy or resulting childbirth or elective abortion; e) participation as a professional in athletics; f) participation in organized amateur and interscholastic athletic or sports competition or events; g) riding or driving in any motor competition; h) declared or undeclared war, or any act of war; i) civil disorder; j) service in the armed forces of any country; k) nuclear reaction, radiation or radioactive contamination; l) operating or learning to operate any aircraft, as pilot or crew; m) mountain climbing, bungee cord jumping, skydiving, parachuting, hang gliding, parasailing or travel on any air supported device, other than on a regularly scheduled airline or air charter company; n) any unlawful acts, committed by you or a Traveling Companion (whether insured or not); o) any amount paid or payable under any Worker's Compensation, Disability Benefit or similar law; p) Elective Treatment and Procedures; q) medical treatment during or arising from a Trip undertaken for the purpose or intent of securing medical treatment; q) a loss that results from an illness, disease, or other condition, event or circumstance which occurs at a time when this policy is not in effect for you. WHEN COVERAGE ENDS Your coverage automatically ends on the earlier of: (1) the date the Trip is completed; (2) the Scheduled Return Date; (3) your arrival at the return destination on a roundtrip, or the destination on a one-way trip; (4) cancellation of the Trip covered by the plan. All coverages under the plan will be extended if your entire Trip is covered by the policy and your return is delayed by unavoidable circumstances beyond your control. If coverage is extended for the above reasons, coverage will end on the earlier of the date you reach your originally scheduled return destination or seven (7) days after the Scheduled Return Date. GENERAL PROVISIONS CONCEALMENT OR FRAUD We do not provide coverage if you have intentionally concealed or misrepresented any material fact or circumstance relating to this policy. CONFORMITY TO LAW Any provision of this plan that is in conflict with the laws of the state in which it is issued is amended to conform with the laws of that state. TAHC5100IPS Page 6

7 DUPLICATION OF COVERAGE You may only purchase one policy from us for each Trip. If you do purchase more than one policy for a specific Trip, the maximum limit of coverage payable will be as specified in the policy with the highest level of benefits. We will refund premiums received from you under any other policy. ENTIRE CONTRACT; CHANGES Any statement you make is a representation and not a warranty. No statement will be used by us to void or reduce benefits unless that statement is a part of any written application form. This policy may be changed at any time by written agreement between us. Only our, Vice or may change or waive the provisions of this plan. No agent or other person may change this plan or waive any of its terms. The change will be endorsed on this plan. EXAMINATION UNDER OATH As often as we may reasonably require, you or any person making a claim under this plan must submit to examination under oath. MAXIMUM BENEFIT AMOUNT The maximum benefit amount for each claim is listed in the Schedule or application form, subject to the individual benefit amount and the company s maximum limit of liability. The total limit of our liability for any one covered event, in which two or more persons submit a claim, is subject to the individual benefit amount and the company s maximum limit of liability. In the event of multiple claims by you for one event, the available funds will be distributed in order of notice of claim by each insured subject to the above limitations. OUR RIGHT TO RECOVER FROM OTHERS We have the right to recover any payments we have made from anyone who may be responsible for the loss. You and anyone else we insure must sign any papers and do whatever is necessary to transfer this right to us. You and anyone else we insure will do nothing after the loss to affect our right. CLAIMS PROVISIONS NOTICE OF CLAIM We must be given written notice of claim within 90 days after a covered loss occurs. If notice cannot be given within that time, it must be given as soon as reasonably possible. Notice may be given to us or to our authorized agent. Notice should include the claimant s name and enough information to identify him or her. PROOF OF LOSS Written Proof of Loss must be sent to us within 90 days after the date the loss occurs. We will not reduce or deny a claim if it was not reasonably possible to give us written Proof of Loss within the time allowed. In any event, you must give us written Proof of Loss within twelve (12) months after the date the loss occurs unless the Insured is legally incapacitated. PHYSICAL EXAMINATION AND AUTOPSY At our expense, we have the right to have you examined as often as necessary while a claim is pending. At our expense, we may require an autopsy unless the law or your religion forbids it. LEGAL ACTIONS No legal action may be brought to recover on this plan within 60 days after written proof of loss has been given. No such action will be brought after three years from the time written proof of loss is required to be given. If a time limit of this plan is less than allowed by the laws of the State where you live, the limit is extended to meet the minimum time allowed by such law. PAYMENT OF CLAIMS Benefits for loss of life will be paid to your estate, or if no estate, your beneficiary. All other benefits are paid directly to you, unless otherwise directed. Any accrued benefits unpaid at your death will be paid to your estate, or if no estate, to your beneficiary. If you have assigned your benefits, we will honor the assignment if a signed copy has been filed with us. We are not responsible for the validity of any assignment. TAHC5100IPS Page 7

8 AMENDMENT This Amendment is part of the Policy to which it is attached. The Policy is amended as follows for residents of the State of Washington. Paragraph One under the ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS is deleted in its entirety and replaced by the following: We will pay this benefit up to the amount on the Schedule if you are injured in an Accident which occurs while you are on a Trip and covered under the policy, and you suffer one of the losses listed below with 365 days of the Accident. The Principal Sum is the benefit shown on the Schedule. The AIR FLIGHT BENEFITS is deleted in its entirety and replaced by the following: Air Flight Benefits The benefits provided by the policy for Air Flight applies only if you sustain a covered loss within 365 days of an Accident which occurs while a passenger in or on, boarding or alighting from an aircraft of a regularly scheduled airline or an air charter company that is licensed to carry passengers for hire. Under Item #4 of the EXCLUSIONS section, the following exclusions are deleted in their entirety: g) riding or driving in any motor competition; k) nuclear reaction, radiation or radioactive contamination; and m) mountain climbing, bungee cord jumping, skydiving, parachuting, hang gliding, parasailing or travel on any air supported device, other than on a regularly scheduled airline or air charter company. Under Item #4 of the EXCLUSIONS section, the following exclusion is deleted in its entirety and replaced by the following: c) alcoholism and/or drug addiction This Amendment does not waive, alter or extend any conditions or provisions of the Policy, except to the extent shown above. It is subject to all the terms and limitations of the Policy. This Amendment takes effect and expires concurrently with the Policy to which it is attached. TAHC5100AS.WA Page 8

9 FAMILY MEMBER DEFINITION RIDER This Immediate Family Member Definition Rider is a part of the Policy to which it is attached. It is issued in consideration of payment of the required premium. The term Immediate Family Member, whenever used in the Policy and/or Riders, is hereby replaced with the term Family Member. TAHC5103DEFRS PRE-EXISTING CONDITION EXCLUSION WAIVER RIDER This Pre-Existing Condition Exclusion Waiver Rider is a part of the Policy to which it is attached. It is issued in consideration of payment of the required premium. Item (2) under the Policy Exclusions is waived provided you meet the following requirements: 1) your premium payment is received or, if mailed, is post marked within 15 days of the date your initial Trip deposit is received; 2) you insure all prepaid trip costs that are subject to cancellation penalties or restrictions; and 3) you are not disabled from travel at the time you pay your premium. TAHC5105PEXRS Page 9

10 TRIP DEFINITION RIDER This Trip Definition Rider is a part of the Policy to which it is attached. It is issued in consideration of payment of the required premium. The Policy definition of Trip is deleted and replaced as follows: TRIP means: 1) A period of round-trip travel away from Home to a destination outside your city of residence; the purpose of the trip is business or pleasure and is not to obtain health care or treatment of any kind; the trip has defined departure and return dates specified when an insured enrolls; the trip does not exceed 365 days or 2) A period of one-way travel that starts in the US (except US citizens may begin their trip outside the US, if returning to the US); the purpose of the trip is business or pleasure and is not to obtain health care or treatment of any kind; the trip has defined departure and arrival dates and defined departure and arrival places specified when an insured applies; and the trip does not exceed 31 days in length. TAHC5121DEFRS COVERED TRIP DEFINITION RIDER This Rider is part of the Policy to which it is attached. It is issued in consideration of payment of any required premium. The term Trip, wherever used in the Policy and/or Riders, is hereby replaced with the term Covered Trip. TAHC5122DEFRS Page 10

11 TRAVELING COMPANION DEFINITION RIDER This Traveling Companion Definition Rider is a part of the Policy to which it is attached. It is issued in consideration of payment of the required premium. The Policy definition of Traveling Companion is deleted and replaced as follows: TRAVELING COMPANION means a person whose name appears with you on the same Trip Arrangement and who during the Trip will accompany you. TAHC5114DEFRS SICKNESS DEFINITION RIDER This Sickness Definition Rider is a part of the Policy to which it is attached. It is issued in consideration of payment of the required premium. The Policy definition of Sickness is deleted and replaced as follows: SICKNESS means an illness or disease of the body which requires examination and treatment by a Physician. TAHC5112DEFRS Page 11

12 Stonebridge Casualty Insurance Company Home Office: Columbus, Ohio Travel Insurance Coverage OUTLINE OF COVERAGE 1. Read Your Policy Carefully - This outline of coverage provides a very brief description of some of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you Read Your Policy Carefully! 2. Travel Insurance Coverage - Policies of this category are designed to provide, to persons insured, coverage for a loss resulting from a covered accident while on a trip, subject to any limitations contained in the policy. Coverage is provided for medical expenses incurred as a result of injury or sickness while traveling on a trip. 3. Description of Benefits: Accidental Death And Dismemberment Benefits If you suffer a loss from an accident while on a trip and the loss occurs within 180 days of the accident, we will pay the following benefits: Loss:..Benefits: Life.100% of the benefit amount: Both Hands; Both Feet or Sight of Both Eyes..100% of the benefit amount; One Hand and One Foot 100% of the benefit amount; One Hand and Sight of One Eye..100% of the benefit amount; One Foot and Sight of One Eye 100% of the benefit amount; One Hand; One Foot or Sight of One Eye.50% of the benefit amount. Medical or Dental Expense/Emergency Assistance Benefit If you incur Covered Expenses as a result of Injury or Sickness while traveling on a Trip, we will pay the following benefit: Split Limit Coverage Emergency Medical Evacuation... $250,000 Policy maximum Accident/Sickness Medical Expense... $100,000 Policy maximum Repatriation... $250,000 per Policy included in Medical Evacuation TAHC5100IOS.WA Page 12

13 4. Exclusions: The following exclusion applies to the Accidental Death and Dismemberment coverage: (1) We will not pay for loss caused by or resulting from Sickness of any kind. The following exclusion applies to the Emergency Assistance coverage: (2) We will not pay for loss or expense caused by or incurred resulting from a Pre-Existing Condition, as defined in this policy, including death that results therefrom. This Exclusion does not apply to benefits under Covered Emergency Assistance Expenses item #1 and item #2 (emergency medical evacuation) or item #6 (repatriation of remains). The following exclusion applies to the Medical or Dental Expense coverage: (3) We will not pay for loss or expense caused by or incurred resulting from a Pre-Existing Condition, as defined in this Policy, including death that results therefrom. The following exclusion applies to all coverage: (4) We will not pay for any loss under this policy, caused by, or resulting from: (a) suicide, attempted suicide, or intentionally self-inflicted injury of you, a Traveling Companion, or Immediate Family Member booked to travel with you, while sane or insane; (b) mental, nervous, or psychological disorders; (c) alcoholism and/or drug addiction; (d) normal pregnancy or resulting childbirth or elective abortion; (e) participation as a professional in athletics; (f) participation in organized amateur and interscholastic athletic or sports competition or events; (g) declared or undeclared war, or any act of war; (h) civil disorder; (i) operating or learning to operate any aircraft, as pilot or crew; (j) any unlawful acts, committed by you or a Traveling Companion (whether insured or not); (k) any amount paid or payable under any Worker s Compensation, Disability Benefit or similar law; (l) Elective Treatment and Procedures; (m) medical treatment during or arising from a Trip undertaken for the purpose or intent of securing medical treatment; (n) a loss that results from an illness, disease, or other condition, event or circumstance which occurs at a time when this policy is not in effect for you. 5. When Coverage Ends: This coverage automatically ends on the earlier of: (1) the date the Trip is completed; (2) the Scheduled Return Date; (3) your arrival at the return destination on a roundtrip, or the destination on a one-way trip; (4) cancellation of the Trip covered by the plan. All coverages under the plan will be extended if your entire Trip is covered by the policy and your return is delayed by unavoidable circumstances beyond your control. If coverage is extended for the above reasons, coverage will end on the earlier of the date you reach your originally scheduled return destination or seven (7) days after the Scheduled Return Date. TAHC5100IOS.WA Page 13

14 Home Office: Columbus, Ohio ADMINISTRATIVE OFFICE: 100 LIGHT STREET BALTIMORE, MARYLAND This Policy is issued to you. The Policy is issued in consideration of payment of premiums as provided by its terms. We agree to pay benefits in accordance with all the provisions of this Policy. Premiums are payable to us or our agent in amounts as set forth by us. The provisions found on the following attached pages form a part of this Policy as if recited over the signatures shown below. TEN DAY RIGHT TO EXAMINE POLICY If you are not satisfied for any reason, you may return this Policy within 10 days after receipt. Your premium will be refunded. When so returned, the Policy is void from the beginning. Return the Policy to us at our Administrative Office or to our authorized agent. This Policy is executed on the Effective Date, at Columbus, Ohio. INDIVIDUAL TRAVEL INSURANCE POLICY BAGGAGE AND PERSONAL EFFECTS BENEFITS BAGGAGE DELAY BENEFITS PRE-DEPARTURE TRIP CANCELLATION BENEFITS POST-DEPARTURE TRIP INTERRUPTION BENEFITS TRAVEL DELAY BENEFITS NONPARTICIPATING TAHC5200IPS

15 TABLE OF CONTENTS BENEFIT SCHEDULE AND DECLARATIONS... 2 DEFINITIONS... 3 WHO IS ELIGIBLE FOR COVERAGE... 3 WHEN COVERAGE BEGINS... 3 EXCLUSIONS... 3 WHEN COVERAGE ENDS... 3 GENERAL PROVISIONS... 3 CLAIMS PROVISIONS... 4 RIDERS TRAVEL DELAY BENFITS RIDER... 5 BAGGAGE DELAY BENEFITS RIDER... 6 PRE-DEPARTURE TRIP CANCELLATION BENEFITS RIDER... 7 POST-DEPRATURE TRIP INTERRUPTION BENEFITS RIDER... 8 BAGGAGE AND PERSONAL EFFECTS BENEFITS RIDER DECLARATIONS PAGE SCHEDULE Insured: The words "you," "your," and "yours" means the Insured. Policy Number: Refer to your Policy Confirmation Letter Effective Date of Coverage: Refer to your Policy Confirmation Letter Premium Amount: Refer to your Policy Confirmation Letter Benefit Schedule for Plan Code 1STA: Benefit Maximum Benefit Amount Pre-Departure Trip Cancellation % of Trip Cost Insured, up to $50,000 Post-Departure Trip Interruption % of Trip Cost Insured, up to $50,000 Travel Delay... $500 Policy maximum Per Day Limit... $150 per Person Baggage and Personal Effects... $1,500 Policy maximum Baggage Delay... $500 Policy maximum WHO IS ELIGIBLE FOR COVERAGE A person who has arranged to take a Trip, pays the required premium and is a resident of the United States of America. WHEN COVERAGE BEGINS All coverages will take effect on the later of 1) the date the premium has been received by us; 2) the date and time you start your Trip; or 3) 12:01 A.M. Standard Time on the Scheduled Departure Date of your Trip. TAHC5200IPS Page 2

16 BAGGAGE DELAY We will pay up to the amount shown in the Schedule for the cost of reasonable additional clothing and personal articles purchased by you, if your Baggage is delayed for more than 24 hours during the Trip. This coverage terminates upon your arrival at the return destination of your Trip. DEFINITIONS BAGGAGE means luggage, personal possessions, and travel documents taken by you on the Trip. SCHEDULED DEPARTURE DATE means the date on which you are originally scheduled to leave on your Trip. SCHEDULED RETURN DATE means the date on which you are originally scheduled to return to the point where the Trip started or to a different final destination. TRIP means a scheduled trip for which coverage has been elected and the premium paid, and all travel arrangements are arranged prior to the Scheduled Departure Date of the Trip. WHEN COVERAGE ENDS Your coverage automatically ends on the earlier of: (1) The date the Trip is completed; (2) The Scheduled Return Date; (3) Your arrival at the return destination on a roundtrip, or the destination on a one-way trip; (4) Cancellation of the Trip covered by the policy. EXCLUSIONS The following exclusion applies to all coverages: (1) We will not pay for any loss under this policy, caused by, or resulting from: a) declared or undeclared war, or any act of war; b) civil disorder; c) service in the armed forces of any country; d) nuclear reaction, radiation or radioactive contamination; e) any unlawful acts, committed by you or a Traveling Companion (whether insured or not); f) a loss that results from an illness, disease, or other condition, event or circumstance which occurs at a time when this policy is not in effect for you. g) a loss or damage caused by detention, confiscation, or destruction by customs. GENERAL PROVISIONS CONCEALMENT OR FRAUD We do not provide coverage if you have intentionally concealed or misrepresented any material fact or circumstance relating to this plan. CONFORMITY TO LAW Any provision of this plan that is in conflict with the laws of the state in which it is issued is amended to conform with the laws of that state. DUPLICATION OF COVERAGE You may only purchase one certificate from us for each Trip. If you do purchase more than one policy for a specific Trip, the Maximum Limit of Coverage payable will be as specified in the policy with the highest level of benefits. We will refund premiums received from you under any other policy. ENTIRE CONTRACT; CHANGES Any statement you make is a representation and not a warranty. No statement will be used by us to void or reduce benefits unless that statement is a part of any written application form. TAHC5200IPS Page 3

17 This plan may be changed at any time by written agreement between us. Only our, Vice or may change or waive the provisions of this plan. No agent or other person may change this plan or waive any of its terms. The change will be endorsed on this plan. EXAMINATION UNDER OATH As often as we may reasonably require, you or any person making a claim under this plan must submit to examination under oath. MAXIMUM BENEFIT AMOUNT The maximum benefit amount for each claim is listed in the Schedule or application form, subject to the individual benefit amount and the company s maximum limit of liability. The total limit of our liability for any one covered event, in which two or more persons submit a claim, is subject to the individual benefit amount and the company s maximum limit of liability. In the event of multiple claims by you for one event, the available funds will be distributed in order of notice of claim by each insured subject to the above limitations. OUR RIGHT TO RECOVER FROM OTHERS We have the right to recover any payments we have made from anyone who may be responsible for the loss. You and anyone else we insure must sign any papers and do whatever is necessary to transfer this right to us. You and anyone else we insure will do nothing after the loss to affect our right. CLAIMS PROVISIONS NOTICE OF CLAIM We must be given written notice of claim within 90 days after a covered loss occurs. If notice cannot be given within that time, it must be given as soon as reasonably possible. Notice may be given to us or to our authorized agent. Notice should include the claimant s name and enough information to identify him or her. PROOF OF LOSS Written Proof of Loss must be sent to us within 90 days after the date the loss occurs. We will not reduce or deny a claim if it was not reasonably possible to give us written Proof of Loss within the time allowed. In any event, you must give us written Proof of Loss within twelve (12) months after the date the loss occurs unless the Insured is legally incapacitated. PHYSICAL EXAMINATION AND AUTOPSY At our expense, we have the right to have you examined as often as necessary while a claim is pending. At our expense, we may require an autopsy unless the law or your religion forbids it. LEGAL ACTIONS No legal action may be brought to recover on this plan within 60 days after written proof of loss has been given. No such action will be brought after three years from the time written proof of loss is required to be given. If a time limit of this plan is less than allowed by the laws of the State where you live, the limit is extended to meet the minimum time allowed by such law. PAYMENT OF CLAIMS Benefits for loss of life will be paid to your estate, or if no estate, your beneficiary. All other benefits are paid directly to you, unless otherwise directed. Any accrued benefits unpaid at your death will be paid to your estate, or if no estate, to your beneficiary. If you have assigned your benefits, we will honor the assignment if a signed copy has been filed with us. We are not responsible for the validity of any assignment. TAHC5200IPS Page 4

18 TRAVEL DELAY BENEFITS RIDER This Rider is a part of the Policy to which it is attached. It is issued in consideration of the payment of the required premium. If your Trip is delayed for 8 hours or more, we will reimburse you up to the amount shown in the Schedule for reasonable additional expenses incurred by you for hotel accommodations, meals, telephone calls and local transportation while you are delayed. We will not pay benefits for expenses incurred after travel becomes possible. Travel Delay must be caused by or result from: 1) Common Carrier delay; or 2) loss or theft of your passport(s), travel documents or money; or 3) quarantine; or 4) hijacking; or 5) natural disaster; or adverse weather; or 6) Injury or Sickness of you, an Immediate Family Member traveling with you; or 7) death of you, an Immediate Family Member traveling with you, or a Traveling Companion. Benefits are subject to all terms and conditions of the Policy. This rider does not waive, alter or extend any TAHC5216BRS Page 5

19 BAGGAGE DELAY BENEFITS RIDER This Rider is a part of the Policy to which it is attached. It is issued in consideration of the payment of the required premium. The Baggage Delay Benefit of the Policy is deleted and replaced as follows: BAGGAGE DELAY We will pay up to the amount shown in the Schedule for the cost of reasonable additional clothing and personal articles purchased by you, if your Baggage is delayed for more than 24 hours during the Trip. We will also reimburse you up to $25 for expenses incurred during your Trip to expedite the return of your delayed Baggage. This coverage terminates upon your arrival at the return destination of your Trip. TAHC5201BRS Page 6

20 PRE-DEPARTURE TRIP CANCELLATION BENEFITS RIDER This Rider is a part of the Policy to which it is attached. It is issued in consideration of payment of the required premium. Pre-departure Trip Cancellation will take effect at 12:01 a.m. Standard Time on the day after the date your premium payment is received or postmarked. Pre-Departure Trip Cancellation We will pay a Pre-Departure Trip Cancellation Benefit, up to the amount in the Schedule/Declarations, if you are prevented from taking your Trip due to your, an Immediate Family Member's or Traveling Companion's Sickness, Injury or death, that occurs before departure on your Trip. The Sickness or Injury must: a) commence while your coverage is in effect under the Policy; b) require the examination and treatment by a Physician, in person, at the time the Trip is canceled; and c) in the written opinion of the treating Physician, be so disabling as to prevent you from taking your Trip. We will pay a benefit if you are prevented from taking your Trip due to Other Covered Events, as defined, that occur before departure on your Trip. Pre-Departure Trip Cancellation Benefit We will reimburse you, to the amount in the Schedule/Declarations, for the amount of forfeited, prepaid, nonrefundable, non-refunded, and published payments or deposits that you paid for your Trip. We will pay your additional cost arrangements if a Traveling Companion's Trip is canceled and your Trip is not canceled. TAHC5212BRS Page 7

21 POST-DEPARTURE TRIP INTERRUPTION BENEFITS RIDER This Rider is a part of the Policy to which it is attached. It is issued in consideration of payment of the required premium. The Post-Departure Trip Interruption Benefit is effective on the Scheduled Departure Date of your Trip. Post Departure Trip Interruption We will pay a Post-Departure Trip Interruption Benefit, up to the amount in the Schedule/Declarations, if: 1) your arrival on your Trip is delayed beyond the Scheduled Departure Date due to your, an Immediate Family Member s, or Traveling Companion s Sickness or Injury; or 2) you are unable to continue on your Trip after you have departed on your Trip due to your, an Immediate Family Member's, or Traveling Companion's Sickness, Injury or death. For item 1) above, the Sickness or Injury must: a) commence while your coverage is in effect under the policy; b) for item 2) above, commence while you are on your Trip and your coverage is in effect under the policy; and c) for both items 1) and 2) above, require the examination and treatment by a Physician at the time the Trip is interrupted or delayed; and d) in the written opinion of the treating Physician, be so disabling as to delay your arrival on your Trip or to prevent you from continuing your Trip. We will pay a benefit if: 1) your arrival on your Trip is delayed beyond the Scheduled Departure Date due to Sickness, Injury or death as defined above; or 2) you are unable to continue on your Trip after you have departed on your Trip due to Other Covered Events, as defined. Post-Departure Trip Interruption Benefit We will reimburse you, less any refund paid or payable, for unused land or water travel arrangements, plus one of the following: 1. The additional transportation expenses by the most direct route from the point you interrupted your Trip: a. To the next scheduled destination where you can catch up to your Trip; or b. To the final destination of your Trip; or 2. The additional transportation expenses incurred by you by the most direct route to reach your original Trip destination if you are delayed and leave after the Scheduled Departure Date. However, the benefit payable under (1) and (2) above will not exceed the cost of a one-way economy air fare (or first class, if the original tickets were first class) by the most direct route less any refunds paid or payable for your unused original tickets. 3. Your additional cost as a result of a change in the per-person occupancy rate for prepaid travel arrangements if a Traveling Companion's Trip is interrupted and your Trip is continued. TAHC5219BRS Page 8

22 OTHER COVERED EVENTS DEFINITION RIDER This Rider is a part of the Policy to which it is attached. It is issued in consideration of the payment of the required premium. The following definitions are added to the Definitions section: OTHER COVERED EVENTS means only the following unforeseeable events or their consequences which occur while coverage is in force under this Policy: 1. Air Carrier delays resulting from organized labor strikes that affect public transportation; 2. Arrangements canceled by an airline, cruise line or tour operator resulting from inclement weather or organized labor strikes that affect public transportation. 3. A change in plans by you, an Immediate Family Member traveling with you, or your Traveling Companion resulting from one of the following events which occurs while coverage is in force under this Policy: (a) (b) (c) (d) (e) (f) (g) being directly involved in a documented traffic accident while en route to departure; being hijacked, quarantined, required to serve on a jury, or required by a court order to appear as a witness in a legal action, provided you, a Family Member traveling with you or a Traveling Companion is not 1) a party to the legal action, or 2) appearing as a law enforcement officer; having a residence made uninhabitable by fire, flood, volcano, earthquake, hurricane or other natural disaster; being called into active military service to provide aid or relief in the event of a natural disaster; a documented theft of passports or visas; a transfer of employment of 250 miles or more; a Terrorist Act which occurs in your departure city or in a city which is a scheduled destination for your Trip provided: 1) the Terrorist Act occurs within 30 days of the scheduled departure date for your Trip and 2) your premium is received within 7 days of the initial deposit/payment for your Trip. The following definitions are added to the Policy: AIR CARRIER means any air conveyance operated under a license for the transportation of passengers for hire. TERRORIST ACT means an act of violence other than civil disorder or riot, (that is not an act of war, declared or undeclared) that results in loss of life or major damage to property, by any person acting on behalf of or in connection with any organization which is generally recognized as having the intent to overthrow or influence the control of any government. TAHC5262DEFRS Page 9

23 OTHER COVERED EVENTS DEFINITION RIDER This Rider is a part of the Policy to which it is attached. It is issued in consideration of payment of the required premium. The following definitions are added to the Definitions section: OTHER COVERED EVENTS means only the following unforeseeable events or their consequences which occur while coverage is in force under this Policy: 1. Common Carrier delays resulting from bad weather, mechanical breakdown of the aircraft, ship or boat or motor coach on which you are scheduled to travel or organized labor strikes that affect public transportation; 2. arrangements canceled by an airline, cruise line, or tour operator resulting from inclement weather, mechanical breakdown, or organized labor strikes that affect public transportation. Items #1 and #2 above, are subject to the following conditions: (a) the scheduled carrier connecting times must meet airline legal minimum connect times; and (b) the scheduled time between arrival at the Scheduled Tour/Cruise Departure City and the scheduled tour/cruise departure must be 2 hours or longer. 3. arrangements canceled by an airline, cruise line, or tour operator, resulting from Financial Insolvency; Item #3 above, is subject to the following condition: The Insured s premium must be received prior to or with the final payment for his Trip; 4. a change in plans by the Insured, an Immediate Family Member traveling with the Insured, or Traveling Companion, resulting from one of the following events which occurs while coverage is in force under this Policy: (a) being directly involved in a documented traffic accident while en route to departure; (b) being hijacked, quarantined, required to serve on a jury, or required by a court order to appear as a witness in a legal action, provided the Insured, an Immediate Family Member traveling with the Insured or a Traveling Companion is not 1) a party to the legal action, or 2) appearing as a law enforcement officer; (c) your home made uninhabitable by fire, flood, volcano, earthquake, hurricane or other natural disaster; (d) being called into active military service to provide aid or relief in the event of a natural disaster; (e) a documented theft of passports or visas; (f) a Terrorist Act (or acts) which occurs in the Insured s departure city or in a city which is a scheduled destination for the Insured s Trip provided the Terrorist Act (or acts) occurs within 30 days of the Scheduled Departure Date for the Insured s Trip; (g) a cancellation of your Trip if your arrival on the trip is delayed and causes you to lose 50% or more of the scheduled trip duration due to the reasons covered under the Travel Delay Benefit. The following definition is added to the Policy: SCHEDULED TOUR/CRUISE DEPARTURE CITY means the city where the scheduled tour/cruise on which you are to participate originates. TAHC5241DEFRS Page 10